CA Payers Tackle Provider Directories with Data, Collaboration

January 29, 2019 - Provider directories are often a patient’s primary source of information when making decisions about their care and coverage. Healthcare consumers use these directories to find out which providers are in their health plan’s network or whether providers are accepting new patients – fundamental research that requires accurate and up-to-date information.

However, maintaining trustworthy provider directories is a challenging, expensive process. Plans tweak their networks on a regular basis, and professionals can change jobs or credentials frequently, leaving payers and consumers playing catch-up.

“In California, there is a big problem with inaccurate data in provider directories. Based on the 2018 CMS audit, nearly 50 percent of data in online directories has at least one inaccuracy,” Eyal Gurion, Senior Vice President, GM Symphony Provider Directory, told HealthPayerIntelligence.com.

Network and employment changes are only half the battle, he added. Fragmented health IT systems are also to blame.

“It isn’t because health plans and provider organizations don't care – they do,” he stressed. “But every health plan has invested in multiple solutions, systems, and portals with their provider networks, and this makes things complicated. If I'm a provider and I contract with 15 or 20 health plans, I might need to accommodate 15 or 20 different processes, formats, and requirements.”

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To improve the accuracy of provider directory data in California, IHA recently launched the Symphony Provider Directory, a centralized online service where providers and plans can exchange and reconcile provider information.

Funded by a $50 million grant from Blue Shield of California, the new directory is the result of collaboration between providers, plans, and regulators, who aim to improve data quality and streamline processes.

“The Symphony Provider Directory is a great example of how IHA is bringing in key stakeholders to work together and develop a single platform to manage provider directory data in the state,” said Gurion.

“Building a statewide utility is no easy task. It's complicated, and that's why we need everyone working together to make that happen.”

In 2017, Blue Shield of California and the California Department of Managed Health Care selected IHA to develop a statewide provider directory. IHA soft-launched the service in August 2018 with participation from Anthem Blue Cross, Health Net, and Blue Shield of California, as well as; two large provider organizations and ten independent practices and clinics.

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“We set out to build a single platform that would enable providers to update and manage provider directory data for all of their contracted health plans,” said Gurion.

“On the provider and plan side, we were aiming to streamline processes and achieve better data quality and accuracy. We also wanted to provide better data for consumers as they make healthcare purchasing decisions.”

During the soft launch, IHA found a significant need to improve the quality of provider data. The organization found that 31 percent of providers that should have been listed in a health plan’s online directory were not there.

In the coming months, the Symphony Provider Directory will work to improve provider directories by encouraging plans and providers to participate in the service.

The more plans and providers that participate, the better the data quality, which will help consumers make more informed care and coverage decisions, Gurion said.

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“This solution maximizes value by building a critical mass of providers and plans. We need to have all the plans, or a critical mass of plans and providers, using this platform to establish the Symphony Provider Directory as the status quo in California,” he said.

In addition to improving data quality, the platform will reduce administrative burden on providers and plans by simplifying regulatory compliance, Gurion noted.

“Compliance is a critical issue in California. Senate Bill 137, Medicare Advantage, and Medi-Cal regulations require both plans and providers to send specific data elements in a timely, standardized manner,” he said.  

“This utility is supporting both plans and providers in meeting compliance requirements. The specific requirements are already integrated into the platform.”

The platform is also designed to integrate with existing systems and processes, making it simple for health plans to join this effort.

“We know that health plans have large, complex systems, and that it is difficult to make changes to these systems. We strive to meet plans where they are. We take the data and standardize those elements on the Symphony Provider Directory level,” Gurion explained.

“When the provider needs to update their information, they update the information in one place, and then we send it back to the plans in a way that enables them to ingest the data. We don't ask them to change their systems. We map and integrate to their systems, allowing them to join us much more easily.”

The full-scale launch of the Symphony Provider Directory will align with California’s goal of healthcare coverage for all residents. Several new initiatives from California Governor Gavin Newsom will aim to address the rising costs of prescription drugs and improve care access for individuals across the state.

“As we think about more and more people getting coverage, and more and more people needing to choose health plan products, it is incredibly important that those people have access to the right information around the products and networks that they're choosing,” Gurion said.

“Essentially, we're building infrastructure that will support any expansion in California.”

IHA is planning to have at least 80 percent of California providers and plans participating in the Symphony Provider Directory by 2023. To further incentivize participation, the new platform will be fully subsidized for health plans and providers throughout 2019.

IHA will also work to ensure providers are aligning their data with California regulations and updating it to improve consumer decision-making.

“A big focus for us is outreach education with the provider community. We want to make sure that providers and administrators know what data they need to send to the utility, how that data is being used, and why it's important for them to update their data on an ongoing basis,” Gurion said.

“Provider outreach and education is a critical component of what we did in 2018, as well as our strategy going forward.”

By joining together plans, providers, and regulators, IHA expects that the Symphony Provider Directory will lead to improved provider data and more accurate consumer information.

“What's unique about this initiative is the multi-stakeholder approach. Plans, provider organizations, and large health systems that normally compete in the marketplace are working with us to find a solution that benefits the industry,” Gurion concluded.

“We are really breaking down silos and working together to make sure that data flows efficiently between providers and plans, and ultimately delivering better information to the consumers. Bringing everyone together is a key component in everything that we do, and it’s what is driving breakthrough improvements in California.”